Medical transcription

Medical transcription, also known as MT, is an allied health profession, which deals in the process of transcription, or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals, into text format

Transcription

Transcription is the conversion into written, typewritten or printed form, of a spoken-language source, as in the proceedings of a court hearing. It can also mean the conversion of a written source into another medium, as by scanning books and making digital versions. A transcriptionist is a person who performs transcription.

In a strict linguistic sense, transcription is the process of matching the sounds of human speech to special written symbols, using a set of exact rules, so that these sounds can be reproduced later.

Allied health professions

Allied health professions are clinical healthcare professions distinct from medicine, dentistry, and nursing. They work in a healthcare team to make the healthcare system function.

History

The evolution of transcription dates back to the 1960s. The method was designed to assist in the manufacturing process. The first transcription that was developed in this process was MRP, which is the acronym for Manufacturing Resource Planning, in 1975. This was followed by another advanced version namely MRP2. But none of them yielded the benefit of medical transcription.

However, transcription equipment has changed from manual typewriters to electric typewriters to word processors to computers and from plastic disks and magnetic belts to cassettes and endless loops and digital recordings. Today, speech recognition (SR), also known as continuous speech recognition (CSR), is increasingly being used, with medical transcriptionists and or "editors" providing supplemental editorial services, although there are occasional instances where SR fully replaces the MT. Natural-language processing takes "automatic" transcription a step further, providing an interpretive function that speech recognition alone does not provide (although MTs do).

In the past, these medical reports consisted of very abbreviated handwritten notes that were added in the patient's file for interpretation by the primary physician responsible for the treatment. Ultimately, this mess of handwritten notes and typed reports was consolidated into a single patient file and physically stored along with thousands of other patient records in a wall of filing cabinets in the medical records department. Whenever the need arose to review the records of a specific patient, the patient's file would be retrieved from the filing cabinet and delivered to the requesting physician. To enhance this manual process, many medical record documents were produced in duplicate or triplicate by means of carbon copy.

Basic MT knowledge, skills and abilities

• Knowledge of basic to advanced medical terminology is essential.
• Average verbal communication skills.
• Above-average memory skills.
• Ability to sort, check, count, and verify numbers with accuracy.
• Demonstrated skill in the use and operation of basic office equipment/computer.
• Ability to follow verbal and written instructions.
• Records maintenance skills or ability.
• Above-average typing skills.
• Knowledge and experience transcribing (from training or real report work) in the Basic Four work types.
• Knowledge of and proper application of grammar.
• Knowledge of and use of correct punctuation and capitalization rules.
• Demonstrated MT proficiencies in multiple report types and multiple specialties.

Applications

Health care

In the health care domain, even in the wake of improving speech recognition technologies, medical transcriptionists (MTs) have not yet become obsolete. Many experts in the field^[who?] anticipate that with increased use of speech recognition technology, the services provided may be redistributed rather than replaced.

Speech recognition can be implemented in front-end or back-end of the medical documentation process.

Front-End SR is where the provider dictates into a speech-recognition engine, the recognized words are displayed right after they are spoken, and the dictator is responsible for editing and signing off on the document. It never goes through an MT/editor.

Back-End SR or Deferred SR is where the provider dictates into a digital dictation system, and the voice is routed through a speech-recognition machine and the recognized draft document is routed along with the original voice file to the MT/editor, who edits the draft and finalizes the report. Deferred SR is being widely used in the industry currently.

Many Electronic Medical Records (EMR) applications can be more effective and may be performed more easily when deployed in conjunction with a speech-recognition engine. Searches, queries, and form filling may all be faster to perform by voice than by using a keyboard.

Dictation

Dictation can refer to:

• Dictation, when one person speaks while another person transcribes what is spoken.
• A machine/device used to record this speech for transcription.
• Dictaphone, a company that manufactures these devices, and which are often known generically by this name.
• Digital dictation, the use of digital electronic media for this purpose, and often computerized speech recognition.

Hospital

A hospital is an institution for health care providing patient treatment by specialized staff and equipment, and often but not always providing for longer-term patient stays.

Today, hospitals are usually funded by the state, by health organizations, health insurances or charities, including by direct charitable donations. In history, however, hospitals were often founded and funded by religious orders or charitable individuals and leaders. Similarly, modern-day hospitals are largely staffed by professional physicians, surgeons, and nurses, whereas in history, this work was usually done by the founding religious orders or by volunteers.

A physician

A physician, medical practitioner, doctor of medicine, or medical doctor practices medicine, and is concerned with maintaining or restoring human health through the study, diagnosis, and treatment of disease and injury. This is accomplished through a detailed knowledge of anatomy, physiology, diseases and treatment — the science of medicine — and its applied practice — the art or craft of medicine.

Medical Transcription Equipment Menu

Desktop Microphone Dictation

Digital Voice Recorders

Dragon NaturallySpeaking Versions

EMDAT InScribe ® Foot Pedal

Foot Pedals: Universal & Brand

Headsets: Universal

Headset Ear Cushion Replacements

Memory Stick Adaptors

Memory Sticks

Microphones

Microcassette Voice Recorders

Olympus Conference Kit

Olympus DR-1000

Olympus DR-1000 Exec

Olympus DS-2400

Olympus DS-30

Olympus DS40

Olympus DS-4000

Olympus DS-50

Olympus DS-5000

Olympus DS-5000iD

Olympus DS-71

Philips SpeechMike 5282

Philips SpeechMike 5284

Philips SpeechMike Classic 5262

Philips SpeechMike Classic Plus 5272

Philips SpeechMike Pro 5274

Philips SpeechMike Pro Plus 5276

Phone-In Systems

Sanyo TRC-540M

Sanyo TRC-5830

Sanyo TRC-590M

Sony BM-575

Sony ICD-BM1A

Sony ICD-BM1AVTP

Sony ICD-MX20

Sony ICD-MX20VTP

Sony ICD-SX57

Sony ICD-SX57VTP

Sony M2000

Sony M2020

Stedman's Dictionary

Voice Recorder Applications & Systems

WAVpedal & Voice Recorder Special Packages

WAVpedal version 7.0 Foot Pedal & Software System

WAVpedal Version 7.0 Software Upgrade Only

WordTraverse Line Counter

As a profession

An individual who performs medical transcription is known as a medical transcriptionist or an MT. The equipment the MT uses is called a medical transcriber. The individual who performs medical transcription should always be called a "medical transcriptionist." A medical transcriptionist is the person responsible for converting the patient's medical records into typewritten format rather than a handwritten.

A person who transcribes medical reports dictated by a physician concerning a patient's health care.

There is a great degree of internal debate about which training program best prepares a MT for industry work. Yet, whether one has learned medical transcription from an online course, community college, high school night course, or on-the-job training in a doctor's office or hospital, a knowledgeable MT is highly valued.

Duties and Responsibilities

• Accurately transcribes the patient-identifying information such as name and Medical Record or Social Security Number.
• Transcribes accurately, grammar and spelling, and edits for inconsistencies.
• They consults references for medical procedures and terminology.
• Distributes transcribed reports and collects dictation files.
• Follows up on physicians' missing and/or late dictation, returning report in a timely fashion (in US Hospital, MT Supervisor performs).
• Performs assurance for its quality.
• May maintain backup copy files.
• Resposible for checking the right address and patient's names as it is given by the dictator.

Medical Transcription Process

When the patient visits a doctor, the doctor spends time with the patient discussing his medical problems, including past history and/or problems. The doctor performs a physical examination and may request various laboratory or diagnostic studies. then decides on a plan of treatment for the patient. After the patient leaves the office, the doctor uses a voice-recording device to record the information about the patient encounter. This information may be recorded into a hand-held cassette recorder or into a regular telephone, dialed into a central server located in the hospital or transcription service office, which will 'hold' the report for the transcriptionist.

This report is then accessed by a medical transcriptionist, it clearly received as a voice file or cassette recording, who then listens to the dictation and transcribes it into the required format for the medical record, and of which this medical record is considered a legal document. The next time the patient visits the doctor, the doctor will call for the medical record or the patient's entire chart, which will contain all reports from previous encounters. The doctor can on occasion refill the patient's medications after seeing only the medical record, although doctors prefer to not refill prescriptions without seeing the patient to establish if anything has changed.